Reducing Readmissions for Heart Failure.

Abstract

Heart failure (HF) remains one of the leading diagnoses among hospitalized patients aged 65 years and older in the United States.1 Despite advances in both medical and device therapies for treating HF, the mortality rate within 5 years of the initial diagnosis remains greater than 50%.2 In 2012, costs for treating HF were an estimated $30.7 billion annually. Projected costs are estimated to be $69.7 billion by the year 2030.3 The monetary cost for care is exorbitant, but so are the physical and emotional costs for patients, their families, and the community providing health care to reduce the cycle of readmissions to the hospital because of HF.Hospital readmission for HF, as defined by the Centers for Medicare and Medicaid Services 2013 Measure Methodology Report, is essentially a return admission to a hospital, for any cause, within 30 days of discharge from a prior HF-related hospitalization.4 This definition of 30-day all-cause readmission for HF accounts for a current national readmission rate of 21.6%. The Centers for Medicare and Medicaid Services levy financial penalties on hospitals that report readmission rates at or above the national average.Research suggests that more than 2 readmissions for HF within 1 year predict greater risk of mortality in patients with HF.5 Factors that increase risk for HF-related read-missions are complex and multifactorial; they include age greater than 65 years old, New York Heart Association classes III or IV, high body mass index, comorbidities of diabetes and chronic kidney disease, low muscle strength, impaired gait, and depression.6 At The Valley Hospital in Ridgewood, New Jersey, administrative personnel, physicians, and advanced practice nurses came together in 2012 to develop a comprehensive strategy to reduce 30-day all-cause readmissions among their patients with HF.The strategy began as a pilot project to treat patients with HF in an outpatient ambulatory care setting located within the hospital itself. The team designated 12 beds in an established medical-surgical short-stay unit for providing specialized cardiovascular care to patients with HF. The unit was established informally as the Heart Failure Program but later became the Outpatient Transitional Care Program (OPTCP). The goal of the OPTCP is to provide early intervention, optimize guideline-based treatments, and improve patient self-care management through ongoing education. The OPTCP follow-up visit, scheduled to occur within 7 to 14 days of hospital discharge, is intended to prevent avoidable readmissions for HF. The process during the follow-up visit includes clinically assessing patients, creating individualized care plans, delivering treatment when necessary, providing guidance regarding medication management, and educating patients and their families about HF self-management strategies. The team identified these elements as key evidence-based strategies designed to reduce 30-day all-cause readmission rates for HF within the hospital while streamlining the delivery of high-quality patient care.Implementation of the OPTCP unit in 2012 included multiple initiatives. We started by establishing evidence-based order sets for providers to use with patients with HF; we used dashboards and the existing risk assessment evaluation tool from the case management department to help us identify our patient population and those at highest risk for HF-related readmission. Our information systems department helped develop patient referral consult orders to be printed to the unit to notify us of patients who required OPTCP services. The registered nurses (RNs) on the unit researched, reviewed, and developed patient and family education materials to be used both in the unit and hospital wide. The nurses made phone calls within 48 hours after discharge, and asked disease-specific questions to help audit patient satisfaction and understanding of HF education. Processes were established to help with the ever-increasing need for telephone triage of patients and families calling with questions or concerns about symptoms or medications. Because of the increasing number of patients in the OPTCP, we codeveloped a process and algorithms whereby the hospital’s mobile intensive care unit ambulance, staffed by an RN and paramedics, would visit home-bound patients with HF who need to be evaluated and treated.Since its inception, our unit has focused on patients’ and their families’ ongoing care needs, which are identified at a patient’s initial visit. The OPTCP interprofessional team includes advanced practice nurses, collaborating physicians, RNs, ancillary care staff, registered dieticians, case managers, pharmacists, and social workers. An office coordinator position was created to manage OPTCP scheduling, data entry, and medication preauthorizations and to assist with unit and patient workflow.Referrals to our unit start with properly identifying which patients in the hospital have a diagnosis of HF. To identify currently hospitalized patients with HF and arrange follow up in the OPTCP, the RNs work with the hospital’s information systems department to develop automatic daily lists of patient names and locations. The RNs use this list to schedule OPTCP visits for patients before hospital discharge and to initiate bedside teaching regarding the HF disease process, the importance of monitoring weight, restrictions with a 2-g sodium diet, and monitoring for signs and symptoms of HF.While they are still hospitalized, patients with HF are given appointments to visit the OPTCP after discharge. During the postdischarge visit to the OPTCP, the patient’s vital signs and weight are measured, and blood is drawn to obtain a basic metabolic panel, a complete blood count, and the brain natriuretic peptide concentration. One of the program’s physicians or advanced practice nurses performs a physical examination, noting the patient’s history, reported symptoms, and blood work results. On the basis of this evaluation, early interventions are implemented during the patient’s visit to reduce the risk of hospital readmission. These interventions include, but are not limited to, administering intravenous diuretics, optimizing goal-directed medical therapy for guideline-based treatment of HF, reconciling medications, collaborating to provide appropriate referrals on the basis of clinical visit findings, and reinforcing patient education. Medications are reconciled at the beginning and the end of each visit, highlighting any changes the provider who saw the patient made during that visit. The frequency of patient visits is based on the patient’s acuity, the assessed clinical risk for rehospitalization, and the extent of supportive care services the patient requires.Nurses must reinforce patient and family education regarding self-care management strategies for HF; this reinforcement is a part of the guideline-based interventions for this patient population. Patient and family education is a significant part of each visit to the unit. The inter-professional team comprising advanced practice nurses, physicians, RNs, registered dieticians, and pharmacists came together in July and August 2015 to develop enhanced patient education materials on the basis of Heart Failure Society of America recommendations. The team developed a double-sided placemat for use in educating patients on the signs and symptoms of HF and on proper nutrition (Figure 1). Side 1 of the placemat shows the “heart failure zones,” which help patients identify whether they are currently experiencing HF symptoms or are on the verge of having an exacerbation. Side 2 of the placemat is composed of general patient reminders specific for HF. These reminders consist of low-sodium alternatives when eating or food shopping, and lifestyle reminders such as medication adherence and recommended food portion sizes. Patients review the placemat at each visit.At their initial visit to the OPTCP, patients are given blue canvas bags in which to bring their medication bottles so the team can ensure the accuracy of medication reconciliation. A binder is also provided at the initial visit; it is intended as a place for patients to keep and easily locate information regarding their HF care. Binder sections include sheets on which to record daily weight and symptoms, current medication lists, nutrition and activity reminders, low-sodium recipes, follow-up appointment reminders for subsequent visits to the OPTCP and other physicians, and ongoing laboratory work reports provided at each visit. The hospital’s Patient and Family Advisory Council reviewed and approved the binder in September 2015, and we fully implemented it in October 2015.Because of the initial and ongoing multidisciplinary interventions and processes used to develop and support the unit’s initiatives and goals, we have collected multiple data elements over the years. For the purpose of measuring overall success, we looked at several primary data elements. Satisfaction among patients with HF increased slightly, from 95.3% in 2017 to 95.4% in 2018. The number of patient visits increased from 2720 in 2017 to 2938 in 2018, and the number of referrals to the OPTCP increased from 470 in 2016 to 569 in 2017. Figure 2 compares 30-day readmission rates for HF in our unit with the hospital-wide and national averages.Research supports the effectiveness of a multidisciplinary approach in streamlining the transition of patients with HF from an acute care setting to a home environment while reducing the risk of rehospitalization.7,8 Our unit has successfully reduced 30-day all-cause readmission rates for patients with HF within our community hospital by combining care defined by evidence-based guidelines with resourceful innovations, and by developing a unique transitional care program. The program is designed to meet the many needs of this complex and high-risk patient population. With constant changes in health care delivery and reimbursement, our unit’s practices will need to evolve to meet these ongoing challenges and remain successful.